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Resumen Introduccion y objetivos El acceso transaxilar (ATx) se ha convertido en el acceso alternativo al transfemoral (ATF), mas utilizado en pacientes sometidos a implante percutaneo de valvula aortica (TAVI). El objetivo principal de este estudio es comparar la mortalidad total hospitalaria y a los 30 dias de los pacientes incluidos en el registro espanol de TAVI a los que se trato por acceso ATx frente a ATF. Metodos Se analizo a todos los pacientes incluidos en el registro espanol de TAVI tratados por ATx o ATF. Los eventos hospitalarios y a los 30 dias de seguimiento se definieron segun las recomendaciones de la Valve Academic Research Consortium. Se evaluo el impacto de la via de acceso mediante emparejamiento por puntuacion de propension segun las caracteristicas clinicas y ecograficas. Resultados Se incluyo a 6.603 pacientes, 191 (2,9%) tratados por ATx y 6.412 con ATF. Despues del ajuste (grupo de ATx, n = 113; grupo de ATF, n = 3.035), el exito del dispositivo fue similar entre ambos grupos (el 94% en el grupo de ATx frente al 95% en el de ATF; p = 0,95); sin embargo, se observo un incremento en la tasa de infarto agudo de miocardio (OR = 5,3; IC95%, 2,0-13,8; p = 0,001), complicaciones renales (OR = 2,3; IC95%, 1,3-4,1; p = 0,003) e implante de marcapasos (OR = 1,6; IC95%, 1,01-2,6; p = 0,03) en el grupo de ATx comparado con el de ATF. De mismo modo, la mortalidad hospitalaria y a los 30 dias fueron superiores en el grupo de ATx (respectivamente, OR = 2,2; IC95%, 1,04-4,6; p = 0,039; y OR = 2,3; IC95%, 1,2-4,5; p = 0,01). Conclusiones El ATx se asocia con un aumento en la mortalidad total tanto hospitalaria como a los 30 dias frente al ATF. Ante estos resultados, el ATx debe considerarse solo en caso de que el ATF no sea posible.

Coronary flow reserve (CFR) is a well-validated flow-based physiological parameter that has shown value in clinical risk stratification. CFR can be invasively assessed, classically by Doppler and, more recently, by thermodilution with saline boluses (CFRthermo-bolus). Alternatively, continuous thermodilution is a novel operator-independent, highly-reproducible technique to invasively quantify maximum absolute coronary flow (AF). This study aimed to assess the feasibility of this method to quantify resting AF and to determine CFR (CFRThermo-infusion) as compared with CFRthermo-bolus. Sixty-two consecutive patients with suspicion of coronary disease and absence of significant epicardial lesions were prospectively investigated. AF at maximal hyperemia (20 mL/min) and at lower infusion rates (6-8-10-12 mL/min) were systematically measured using a dedicated catheter and a temperature/pressure guidewire. The absence of baseline Pd/Pa decrease at 6 (0.15 ± 0.2%), 8 (0.17 ± 0.18%) and 10 mL/min (0.2 ± 0.12%) demonstrated absence of hyperemia at ≤10 mL/min (all p = NS). However, at 12 mL/min hyperemia was confirmed by a significant decrease in Pd/Pa (1.3 ± 1.5%, p

OBJECTIVES: To study safety and performance of the MANTA Vascular closure device (VCD) under real world conditions in 10 centers.BACKGROUND: The MANTA is a novel plug-based device for large bore arteriotomy closure.METHODS: We included all eligible patients who underwent transfemoral large bore percutaneous procedures. Exclusion criteria were per operator's discretion and included severe calcification or marked tortuosity of the access vessel, presence of marked obesity/cachexia or a systolic blood pressure above 180 mmHg. The primary performance endpoint was time to hemostasis. Primary and secondary safety endpoints were major and minor access site related vascular complications up to 30 days, respectively. Vascular complications were adjudicated by an independent clinical event committee according to VARC-2 criteria. We performed multivariable logistic regression to estimate the effect of baseline and procedural characteristics on any and major vascular complications.RESULTS: Between February 2018 and July 2019 500 patients were enrolled undergoing Transcatheter aortic valve replacement (TAVR, N = 496), Balloon aortic valvuloplasty (BAV, N = 2), Mechanical circulatory support (MCS, N = 1) or Endovascular aneurysm repair (EVAR, N = 1). Mean age was 80.8 ± 6.6 years with a median STS-score of 2.7 [IQR 2.0-4.3] %. MANTA access site complications were major in 20 (4%) and minor in 28 patients (5.6%). Median time to hemostasis was 50 [IQR 20-120] sec. Severe femoral artery calcification, scar presence in groin, longer procedure duration, female gender and history of hypertension were independent predictors for vascular complications.CONCLUSION: In this study, MANTA appeared to be a safe and effective device for large bore access closure under real-world conditions.

Background: Left atrial appendage occlusion (LAAO) is an accepted strategy for cardioembolic events prevention in patients with non-valvular atrial fibrillation (AF) unsuitable for anticoagulation. However, uncertainties persist regarding the benefit of LAAO in highly-comorbid patients. The aim of this study was to assess the impact of the CHA(2)DS(2)-VASc score beyond thromboembolic risk in predicting clinical outcomes in patients undergoing LAAO. Methods: 160 patients who underwent LAAO were included and categorized into two groups according to their stroke risk (89 with CHA(2)DS(2)-VASc >4 vs. 71 with lower risk). The coprimary endpoints were death and stroke at follow-up. Thromboembolic and bleeding events were compared to those predicted from CHA(2)DS(2)-VASc and HAS-BLED scores. Results: Over a median follow-up of 679 days, CHA(2)DS(2)-VASc >4 was associated with increased all-cause mortality compared with patients with lower thromboembolic risk (HR: 3.23; 95% CI: 1.28-8.19; p < 0.001). However, the rates of stroke after LAAO were not significantly different between risk groups. The observed annual rates of stroke and major bleeding were lower than predicted. Conclusions: Despite increased long-term mortality in patients with CHA(2)DS(2)-VASc >4, LAAO remains beneficial in reducing stroke and bleeding events in high-risk AF patients unsuitable for anticoagulation. (C) 2020 Elsevier B.V. All rights reserved.

Objectives. To determine the outcome predictors of in-hospital mortality in acute total occlusion of the left main coronary artery (ATOLMA) patients referred to emergent angioplasty and to describe the clinical presentation and the long-term outcome of these patients. Background. ATOLMA is an uncommon angiographic finding that usually leads to a catastrophic presentation. Limited and inconsistent data have been previously reported regarding true ATOLMA, yet comprehensive knowledge remains scarce. Methods. This is a multicenter retrospective cohort that includes patients presenting with myocardial infarction due to a confirmed ATOLMA who underwent emergency percutaneous coronary intervention (PCI). Results. In the period of the study, 7930 emergent PCI were performed in the five participating centers, and 46 of them had a true ATOLMA (0.58%). At admission, cardiogenic shock was present in 89% of patients, and cardiopulmonary resuscitation was required in 67.4%. All the patients had right dominance. Angiographic success was achieved in 80.4% of the procedures, 13 patients (28.2%) died during the catheterization, and the in-hospital mortality rate was 58.6% (27/46). At one-year and at the final follow-up, 18 patients (39%) were alive, including four cases successfully transplanted. Multivariate analysis showed that postprocedural TIMI flow was the only independent predictor of in-hospital mortality (OR 0.23, (95% CI 0.1–0.36), p<0.001). Conclusions. Our study confirms that the clinical presentation of ATOLMA is catastrophic, presenting a high in-hospital mortality rate; nevertheless, primary angioplasty in this setting is feasible. Postprocedural TIMI flow resulted as the only independent predictor of in-hospital mortality. In-hospital survivors presented an encouraging outcome. ATOLMA and left dominance could be incompatible with life.

Transcatheter aortic valve replacement (TAVR) is an accepted treatment in patients with severe aortic stenosis. Dedicated and validated computer simulation modeling offers additional information, a...

ObjectiveLeft atrial appendage (LAA) thrombus has heretofore been considered a contraindication to percutaneous LAA closure (LAAC). Data regarding its management are very limited. The aim of this study was to analyse the medical and invasive treatment of patients referred for LAAC in the presence of LAA thrombus.MethodsThis multicentre observational registry included 126 consecutive patients referred for LAAC with LAA thrombus on preprocedural imaging. Treatment strategies included intensification of antithrombotic therapy (IAT) or direct LAAC. The primary and secondary endpoints were a composite of bleeding, stroke and death at 18 months, and procedural success, respectively.ResultsIAT was the preferred strategy in 57.9% of patients, with total thrombus resolution observed in 60.3% and 75.3% after initial and subsequent IAT, respectively. Bleeding complications and stroke during IAT occurred in 9.6% and 2.9%, respectively, compared with 3.8% bleeding and no embolic events in the direct LAAC group before the procedure. Procedural success was 90.5% (96.2% vs 86.3% in direct LAAC and IAT group, respectively, p=0.072), without cases of in-hospital thromboembolic complications. The primary endpoint occurred in 29.3% and device-related thrombosis was found in 12.8%, without significant difference according to treatment strategy. Bleeding complications at 18 months occurred in 22.5% vs 10.5% in the IAT and direct LAAC group, respectively (p=0.102).ConclusionIn the presence of LAA thrombus, IAT was the initial management strategy in half of our cohort, with initial thrombus resolution in 60% of these, but with a relatively high bleeding rate (~10%). Direct LAAC was feasible, with high procedural success and absence of periprocedural embolic complications. However, a high rate of device-related thrombosis was detected during follow-up.

A new collagen-based MANTA vascular closure device (VCD) was developed for closing large-bore arteriotomies after transfemoral transcatheter aortic valve implantation (TAVI). We evaluated safety and feasibility at 30-day follow-up in terms of vascular and bleeding complications and mortality of the collagen-based MANTA VCD compared with the suture-based Prostar XL VCD in a cohort of 366 patients who underwent transfemoral TAVI between January 2015 and April 2018. The MANTA VCD was used in 168 patients and the Prostar XL VCD in 198 patients, with successful closure of 98.8% and 98.5%, respectively. VARC-2 defined as major vascular and bleeding complications was similar in both groups (MANTA vs Prostar XL): 0.6% versus 1.0% (p = 0.661) and 0.6% versus 1.5% (p = 0.102). Minor vascular and bleeding complications, were significantly more frequent (10.7 vs 18.8 %, p = 0.003 and 13.7 vs 19.7%, p = 0.080, respectively) in the Prostar XL cohort. Thirty-day all-cause mortality was 2.7%, without significant difference between the groups (p = 0.278). The MANTA device is a safe and feasible option for vascular access closure in patients undergoing transfemoral TAVI.

Resumen Introduccion y objetivos La hormona tiroidea afecta al metabolismo de todos los tejidos del organismo. El objetivo es analizar la prevalencia y las implicaciones de las alteraciones tiroideas en una cohorte de pacientes consecutivos con diseccion coronaria espontanea (DCE). Metodos Se evaluo a 73 pacientes diagnosticados de DCE y se compararon las caracteristicas y la evolucion clinica de los pacientes eutiroideos frente a los hipotiroideos. Se comparo posteriormente la prevalencia de alteraciones tiroideas y las caracteristicas clinicas de estos pacientes con las de 73 pacientes con sindrome coronario agudo pero sin DCE emparejados por edad, sexo y presentacion clinica. Resultados La media de edad fue 55 ± 12 anos y el 26% tenia hipotiroidismo. Los pacientes con DCE e hipotiroidismo eran todas mujeres (el 100 frente al 69%; p = 0,01), tenian disecciones mas distales (el 74 frente al 41%; p = 0,03), en arterias en tirabuzon (el 68 frente al 41%; p = 0,03) y recibieron tratamiento mas conservador (el 79 frente al 41%; p = 0,007). Durante un seguimiento medio de 4,1 ± 3,8 anos, la tasa de eventos adversos fue del 23%, sin diferencias segun el estado de la funcion tiroidea. La prevalencia de hipotiroidismo fue significativamente mayor en los pacientes con DCE que en el grupo con sindrome coronario agudo sin DCE (el 26 frente al 8%; p = 0,004). Conclusiones Hay una elevada prevalencia de hipotiroidismo en los pacientes con DCE. Los pacientes hipotiroideos con DCE son mas frecuentemente mujeres, tienen disecciones mas distales y en arterias en tirabuzon y reciben tratamiento mas conservador.

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Puerta del Mar OBJECTIVES AND METHODS We aim to evaluate the long-term clinical and intravascular outcomes inACS patients treated with Magnesium-Based Bioresorbable Scaffold(MgBRS).Exclusion criteria:left main disease,bifurcations,ostial lesions,severe tortuosity and calcification,long lesions,high thrombus burden,haemodynamic instability,oral anticoagulants,contraindication to dual-antiplatelet therapy.Primary endpoint was the device-oriented composite end-point(DOCE):cardiac death,target vessel myocardial infarction,and target lesion revascularization(TLR).RESULTS:Between Dec2016 to Dec2018,90patients with ACS underwent PCI with MgBRS.46%patients presented with STEMI.Mean age55.9 ± 9.9,75.6%males and64.4%smokers.OCT was performed in 62patients.Mean scaffold length21.27 ± 7.7mm,mean diameter3.31 ± 0.24mm.15 patients required a second overlapped stent.There were 7complications:5edge dissection;1catheter-induced ostial dissection and 1case of slow-flow.Post-PCI OCT showed in-scaffold area stenosis of3.49 ± 21.29%.At 15months,diameter stenosis was31.95 ± 26.14%and restenosis was observed in 10cases(21.7%).Mean scaffold area shrinked from baseline(7.57 ± 1.77mm2)to15-month follow-up(6.13 ± 2.20mm2).The main mechanism of restenosis was scaffold collapse.DOCE was observed in 13.3%of patients.2patients with target-vessel myocardial infarction due to stent thrombosis.1case had recurrent angina at2weeks because of stent fracture and proximal edge dissection.9cases presented restenosis at different time-points.CONCLUSIONS:MgBRS is feasible in patients presenting ACS.At long-term follow-up,further development is needed to help to resolve these drawbacks

Background The use of ionizing radiation during cardiac catheterization interventions adversely impacts the medical staff. Traditional radiation protection equipment is only partially effective. The Cathpax® radiation protection cabin (RPC) has proven to significantly reduce radiation exposure in electrophysiological and neuroradiology interventions. Our objective was to analyze whether the Cathpax® RPC reduces radiation dose in coronary and cardiac structural interventions in unselected real-world procedures. Methods and results In this nonrandomized all-comers prospective study, 119 consecutive cardiac interventional procedures were alternatively divided into two groups: the RPC group (n = 59) and the non-RPC group (n = 60). No significant changes in the characteristics of patients and procedures, average contrast volume, air kerma (AK), dose area-product (DAP) and fluoroscopy time between both groups were apparent. In the RPC group, the first-operator relative radiation exposure was reduced by 78% at the chest and by 70% at the wrist. This effect was consistent during different types of procedures including complex percutaneous interventions and structural procedures. Conclusions Our study demonstrates, for the first time, that the Cathpax® cabin significantly and efficiently reduces relative operator radiation exposure during different types of interventional procedures, confirming its feasibility in a real-world setting.

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Puerta del Mar BACKGROUND The use of ionizing radiation during cardiac catheterization interventions adversely impacts both the patients and the medical staff. Traditional radiation protection equipment is only partially effective. The Cathpax® radiation protection cabin (RPC) has demonstrated to significantly reduce radiation exposure in electrophysiological and neuroradiology interventions. Our objective was to analyze whether the Cathpax® RPC reduces radiation dose in coronary and cardiac structural interventions in unselected real-world procedures. METHODS AND RESULTS In this non-randomized all-comers prospective study, 119 consecutive cardiac interventional procedures were alternatively divided into two groups: the RPC group (n = 59) and the non-RPC group (n = 60). No significant changes in patients and procedures characteristics, average contrast volume, air kerma (AK), dose area-product (PDA) and fluoroscopy time between both groups were apparent. In RPC group, the first operator relative radiation exposure was reduced by 78% at the chest and by 70% at the wrist. This effect was consistent during different types of procedures including complex percutaneous interventions and structural procedures. CONCLUSIONS Our study demonstrates, for the first time, that the Cathpax® cabin significantly and efficiently reduces relative operator radiation exposure during different types of interventional procedures, confirming its feasibility in a real-world setting. Table 3.Comparison of radiation exposureStructural (n = 12)Coronary (n = 107)pPrimary outcomesFirst operator relative exposure at chest*6.8 ± 33 ± 0.60.06First operator relative exposure at left wrist*19.3 ± 104 ± 1.50.01Secondary outcomesSecond operator relative exposure at chest*2.5 ± 1.21.2 ± 0.20.06First operator dose at chest (E in µSv)59.2 ± 4317.2 ± 50.08First operator dose at left wrist (E in µSv)134.1 ± 9623.4 ± 90.04Second operator dose at chest (E in µSv)19 ± 165.7 ± 20.1Patient exposure (DAP in mGy·cm2)62651 ± 2618059682 ± 142860.8Fluoroscopy time, min (±SD)24.2 ± 715.7 ± 40.2Abstract Figures 1 and 2

Introduction Acute total occlusion of the left main coronary artery (ATOLMA) usually leads to a catastrophic presentation. Prediction of ATOLMA by electrocardiogram (ECG) may contribute to early detection and reperfusion. Limited data have been reported previously. This study aims to identify the admission 12‑leads ECG features that can predict the presence of ATOLMA and in-Hospital mortality in these patients. Methods The admission ECGs findings in 24 patients from the previously reported ATOLMA multicenter registry were compared to the ECGs findings in 15 patients with an acute subtotal occlusion of the left main (ASOLMA) and to 15 patients with anterior ST-elevation myocardial infarction of the proximal left anterior descending (LADp-STEMI). Results Some ECG features at presentation can predict an ATOLMA: QRS left axis deviation (−61.17 ± 9 degrees); ST-segment elevation in aVL (1.9 ± 0.65 mm); absence of ST-segment elevation in V1 (0.0 ± 0.6 mm); bifascicular block (58%); fragmented QRS (62.5%); prolongation of QTc interval (465 ± 19 ms) and of QRS interval (136 ± 12 mm). The multivariate analysis found that the independent predictors to distinguish ATOLMA from ASOLMA were aVL ST-segment deviation (OR 5.6(95% CI 1.5–21), p = 0.01) and absence of V1 ST-segment elevation (OR 27(95% CI 1.4–52), p = 0.01); and from LADp-STEMI was QRS width (OR 1.1(95% CI 1.02–1.2), p = 0.02). Fragmented QRS was the only independent predictor of in-hospital mortality in ATOLMA (OR 0.125(95% CI 0.01–0.81), p = 0.03). Conclusions aVL ST-segment elevation, the absence of V1 ST-segment elevation, left axis deviation, the presence of bifascicular block, and prolongation of QRS and QTc interval are predictors of ATOLMA. Fragmented QRS predicts in-hospital mortality in ATOLMA.

BACKGROUND This study sought to evaluate the clinical outcomes of patients treated with magnesium-based bioresorbable scaffolds (MgBRS) in the context of acute coronary syndromes (ACS) at long-term follow-up (24 months). The study also aims to investigate the MgBRS performance by angiography and the healing and bioresorption pattern by optical coherence tomography (OCT) at 18 months. METHODS Between December 2016 and December 2018, a total of 90 patients admitted for ACS and treated with MgBRS (Magmaris, Biotronik AG, Bulach, Switzerland) were enrolled in a multicenter prospective study. Clinical follow-up was performed in all patients at 24 months and angiographic and OCT follow-up in 51.5% of patients at 18 months. Serial OCT was available in 33 patients (36.7%). RESULTS At a 2-year follow-up, 88.8% were free of symptoms, no cardiac death was reported, and the device-oriented composite event (DOCE): consisting of cardiac death, target vessel myocardial infarction, and target lesion revascularization (TLR) was 13.3%. Stent thrombosis and TLR were observed in 2.2 and 11.1%, respectively. Binary restenosis was observed in 21.7% of cases and in-stent late lumen loss was 0.61 ± 0.75 mm. By serial OCT imaging, the minimal lumen area was significantly reduced greater than 40% (from 6.12 ± 1.59 to 3.5 ± 1.55 mm2, p

Introduction and objectives: Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access. Methods: We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics. Results: A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n = 113 TXA group and n = 3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P = .95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P= .001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P = .003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P = .03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P= .039 and OR, 2.3; 95%CI, 1.2-4.5; P = .01, respectively). Conclusions: Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA. (C) 2021 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Fractional flow reserve (FFR) is the "gold standard" for assessing the physiological significance of coronary disease. In the last decade, several alternative adenosine-free indexes have been proposed in order to facilitate the dissemination of the functional evaluation of coronary stenosis. Our aim was to investigate whether radiographic contrast plus intracoronary nitroglycerin (cFFR-NTG) can predict functional assessment of coronary stenosis offering superior diagnostic agreement with FFR compared to non-hyperemic indexes and contrast mediated FFR (cFFR).Three hundred twenty-nine lesions evaluated with pressure wire in 266 patients were prospectively included in this multicenter study.The ROC curves for cFFR-NTG using an FFR≤0.80 showed a higher accuracy in predicting FFR (AUC=0.97) than resting Pd/Pa (AUC=0.90, P0.01) and cFFR (AUC=0.93.5, P0.01). A significant (P0.01) strong correlation was found between FFR and the four analyzed indexes: Pd/Pa (r=0.78); iFR/RFR (r=0.73); cFFR(r=0.89) and cFFR-NTG (r=0.93). cFFR-NTG showed the closest agreement at Bland-Altman analysis. The cFFR-NTG cut off value0.84 showed the highest negative predictive value (88%), specificity (91%), sensitivity (94%) and accuracy (92%) of the studied indexes.Submaximal hyperemic adenosine-free indexes are an efficient alternative to adenosine for the physiological assessment of epicardial coronary disease. The most accurate index in predicting the functional significance of coronary stenosis using FFR as reference was cFFR-NTG.

There has been rapid progress in transcatheter therapies for mitral regurgitation. These developments have elevated the need for the imager to have a core understanding of the functional mitral valve anatomy. Pre- and intraoperative echocardiography for surgical mitral valve repair for mitral regurgitation has defined contemporary interventional imaging in many ways. The central tenets of these principles apply to interventional imaging of transcatheter mitral valve interventions. However, the heightened emphasis on procedural planning and procedural imaging is one of the new challenges posed by transcatheter interventions. This need for accurate and reliable information has required the imager to be agnostic to the imaging modality. Cardiac computed tomography has become critical in procedural planning in this new paradigm. The expanded use of pre-procedural cardiac magnetic resonance to quantify mitral regurgitation and characterize the left ventricle is another illustration of this newer approach. Other illustrations of the new world of interventional imaging include the expanded use of 3-dimensional (3D) transesophageal echocardiography and real-time fusion of echocardiography and fluoroscopy images. Imaging data are also the basis for computational modeling, 3D printing, and artificial intelligence. These technologies are being increasingly explored to improve therapy selection and prediction of procedural outcomes. This review provides an update of the essentials in present interventional imaging for surgical and transcatheter interventions for mitral regurgitation.

Mitral regurgitation is one of the most prevalent valvulopathies worldwide, and its surgical treatment is not feasible in all cases. The elderly and frail with several comorbidities and left ventricular dysfunction are often managed conservatively. Percutaneous treatment (repair or replacement) of the mitral valve has emerged as a potential option for those patients who are at a high risk for surgery. Mitral valve repair with the Mitraclip device proved both increased safety and mortality reduction in patients with severe mitral regurgitation. On the other hand, in the last decade, percutaneous mitral replacement opened new frontiers in the field of cardiac structural interventions. There are few mitral devices; some are in the early phase of development and some are waiting for CE mark of approval. The evolution of these devices was more complicated compared to the aortic technology due to the native mitral valve's complexity and access. This review aims to provide an overview of the current devices, their specific features, and their potential complications.

Heart failure (HF) is a health issue diffused worldwide, both in developed and developing countries. In the last years, the improvement in medical therapy, resynchronization therapy with implantable cardioverter defibrillators, mechanical circulation support with left ventricular assist devices have improved the prognosis of patients with HF and reduced ejection fraction (EF). In this review, we aim to describe a spectrum of newest devices for the treatment of chronic HF by means of left ventricular (LV) remodeling, renal decongestion, and neuromodulation. The most diffused cause of HF is the coronary disease; in fact, ischemic insults to the heart have complex effects on myocytes and myocardial extracellular matrix. The broad result of these modifications is reflected in variations of LV shape, volume, and efficiency. At present a lot of devices with the purpose of reducing ventricular remodeling are available. In patients with chronic HF and acute decompensation, renal decongestion could also be an important goal to achieve. A rise in central venous pressure and consequently increased renal venous pressure determines pressure raises leading to reductions in renal blood flow, glomerular filtration rate (GFR), urine output, and sodium excretion. An additional mechanism involved in the progression of HF is the increase in sympathetic activation. Recent experiments aiming at increasing the parasympathetic tone by vagal nerve stimulation to normalize the autonomic imbalance have been performed. We will focus on describing these devices, their main procedural characteristics, patient eligibility, procedural results, and clinical outcomes.

Introduction and objectives: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry. Methods: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch >= 2 mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n = 201) or complex strategy (n = 37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization. Results: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P = .48 and 85.6% vs 81.1%; P = .49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P = .58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P = .08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results. Conclusions: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies. (C) 2017 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion y objetivos Hay escasa evidencia sobre el tratamiento de lesiones en bifurcacion en relacion con una oclusion coronaria cronica total (OCT). Este estudio analiza los resultados inmediatos y a medio plazo de pacientes con lesiones en bifurcacion en OCT tratados con 1 stent provisional frente a 2 stents en un registro multicentrico. Metodos Entre enero de 2012 y junio de 2016, se recanalizaron 922 OCT en los 4 centros participantes. De ellas, 238 (25,8%) con lesion en bifurcacion se trataron mediante estrategia simple (n = 201) o compleja (n = 37). Se calculo la puntuacion de propension emparejada para detectar sesgos entre ambos grupos. Los eventos adversos cardiovasculares mayores (MACE) se definieron como muerte cardiaca, infarto y revascularizacion de la lesion diana. Resultados Los exitos angiografico y del procedimiento fueron similares con la tecnica simple (el 94,5 frente al 97,3%; p = 0,48) y con la compleja (el 85,6 frente al 81,1%; p = 0,49), aunque la cantidad de contraste, la dosis de radiacion y el tiempo de fluoroscopia fueron menores con la tecnica simple. Al seguimiento (25 meses), la tasa de MACE fue del 8% de los pacientes con la tecnica simple y el 10,8% de los tratados con 2 stents (p = 0,58). En este grupo hubo tendencia a una menor supervivencia libre de MACE (el 80,1 frente al 69,8%; p = 0,08). Despues del analisis de propension, no se observaron diferencias entre los grupos en los resultados inmediatos ni al seguimiento. Conclusiones Las LB en OCT pueden tratarse de modo similar que las demas bifurcaciones, para las que el stent provisional es la tecnica de eleccion. Despues de la puntuacion de propension emparejada, no hubo diferencias en los resultados inmediatos y a medio plazo entre ambos grupos.

The 4Tech TriCinch Coil System (4Tech Cardio, Galway, Ireland) is a novel percutaneous device for severe functional tricuspid regurgitation (TR) designed to reduce tricuspid annular dimensions. During the development of the TriCinch Coil System, optimization of the anchoring system and its

Objectives. To study the long-term outcomes of rotational atherectomy (RA) for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Background. There is little evidence on the incidence, procedural results and long-term outcomes of RA for CTO PCI. Methods. This registry included data from consecutive patients undergoing CTO PCI at four specialized centers. Major adverse cardiac events (MACE: cardiac death, target-vessel myocardial infarction and ischemia-driven target-vessel revascularization) on follow-up were the primary endpoint. Results. A total of 1003 patients were included. Of these, 35 (3.5%) required RA. As compared with Conventional PCI, RA patients were older (68.9 ± 9.5 vs. 64.6 ± 10.7 years, P = 0.02), had higher prevalence of diabetes (58% vs. 37%, P = 0.01) and of a J-CTO score ≥2 (80% vs. 58%, P = 0.009), driven by severe calcification. Antegrade wire escalation was used more frequently in RA (74% vs. 53%, P = 0.08). RA was performed for balloon failure-to-cross in 51% and failure-to-expand in 49%. One burr was utilized in 86%. The 1.25-mm burr was the largest burr used in 43%. Slow flow/no-reflow was observed in 17%. No other serious RA-related complications were observed. Procedural success was 77% vs. 89% (P = 0.04) in RA vs. Conventional PCI. After a mean follow-up of 658 ± 412 days, MACE rates were similar between groups (15% vs. 13%, P = 0.70). Conclusions. The use of RA in CTO PCI was safe, despite a worse patient risk profile and higher procedural complexity, as compared with conventional techniques. Although procedural success was lower in the RA group, there were no differences in long-term clinical outcomes between groups. © 2016 Wiley Periodicals, Inc.

Mitral valve disease affects more than 4 million people in the United States and it is the second most prevalent valvulopathy in Europe. The gold standard of treatment in these patients is surgical repair or mitral valve replacement. In the last decade, numerous transcatheter therapies have been developed to overcome the increased number of subjects with symptomatic severe mitral regurgitation and high surgical risk. The Mitraclip (Abbott Vascular, Menlo Park, CA), PASCAL (Edwards Lifesciences, Irvine, CA, USA), the Carillon™ Mitral Contour System™ (Cardiac Dimension Inc., Kirkland, WA, USA), the Mitralign™ (Mitralign, Tewksbury, Massachusetts), and the Cardioband (Edwards Lifesciences, Irvine, CA) are the principal percutaneous devices for mitral valve repair. We present an evidence-based clinical update that provides an overview of these technologies and their potential complications.

PURPOSE OF REVIEW: This review aims to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve interventions (TTVI), highlighting potential challenges and future directions. RECENT FINDINGS: Severe tricuspid regurgitation (TR) is a predictor of mortality. However, a sizeable number of patients remain untreated until the end-stage when cardiac surgery presents a prohibitive risk. The emergent need in finding a treatment for patients with TR, deemed for surgery options, has encouraged the development of TTVI. These procedures mimic classical surgery techniques and are mainly divided in four categories: annuloplasty and coaptation devices, edge-to-edge techniques and transcatheter tricuspid valve replacement. Early studies showed promising results, but long-term follow-up data are not available. For patients with severe TR and high surgical risk, several percutaneous options are available. However, these therapies are in a growing phase and bigger studies and long term follow-up are needed to prove their efficacy.

Aims: Percutaneous treatment of coronary chronic total occlusion (CTO) is associated with important arterial remodelling after successful recanalisation. Bioresorbable vascular scaffold (BVS) implantation in CTO has been shown to be feasible and can be of interest when the scaffold achieves complete bioresorption. We sought to evaluate the three-year results in terms of clinical events, serial imaging outcomes and vasomotion response in CTO lesions successfully treated with BVS. Methods and results: A total of 33 patients (35 CTO lesions) successfully treated with BVS were included in the ABSORB-CTO study. Clinical outcomes, quantitative coronary angiography (QCA) and optical coherence tomography (OCT) assessment were analysed at one- and three-year follow-up. Vasomotion examination was also performed at three years. At three years, cumulative target vessel reocclusion was observed in four lesions (11.4%). By QCA, the in-scaffold segment presented a lumen loss of 0.23 +/- 0.46 mm compared with the baseline procedure (p=0.001) and a lumen gain of 0.05 +/- 0.29 mm between one and three years (p=0.220). By OCT, the mean neointimal area stenosis progressed from 11.45% at 12 months to 17.10% at 36 months (p

Patent foramen ovale (PFO) usually represents a benign incidental finding. Occasionally, a PFO can open widely, resulting in paradoxical embolism, with potentially devastating consequence. Floating intracardiac thrombi and thrombus straddling a PFO are 2 extremely rare conditions associated with a dismal prognosis and encountered almost exclusively in the setting of pulmonary embolism (PE). We report the unusual case of a 47-year-old man with an unremarkable medical history who presented with a bilateral PE and multiple paradoxical and intracardiac floating thrombi in the setting of a thrombus entrapped in a PFO.

Objective The aim of this study was to describe the early use of dedicated patient specific computer modeling in patients with bicuspid aortic valve (BAV) undergoing transcatheter aortic valve implantation (TAVI), in predicting procedure feasibility and patient related outcome. Background Dedicated patient specific computer modeling, used for optimizing TAVI procedures, is currently validated for the prediction of contact pressure, valve morphology and paravalvular leakage (PVL). The simulation of TAVI procedures is increasingly used in patients with tricuspid aortic valve stenosis. Currently, BAV disease is considered as a relative contra-indication for TAVI due to its specific anatomical characteristics. Methods This single center study consisted of seven patients with BAV undergoing TAVI. A patient specific computer simulation was performed based on multislice computer tomography images. The model advised the best fitting prosthetic valve size or sizes and simulated this valve on different implantation depths with the corresponding presence and severity of PVL and prosthetic valve morphology. The simulation results were compared with the procedural outcomes using transesophageal echocardiography (TEE) and fluoroscopy. Results The patient specific computer modeling predicted accurately the outcome (PVL and valve morphology) of TAVI in all cases. In one case, the TAVI procedure was unsuccessful and retrospectively not suitable for TAVI, which was correctly predicted by the model. Conclusion The patient specific computer modeling adequately predicts feasibility and outcome of TAVI in patients with BAV disease and may extend the applicability of TAVI. Moreover, it improves decision-making and therefore individual procedural outcomes in this difficult patient population.

A new collagen-based MANTA vascular closure device (VCD) was developed for closing large-bore arteriotomies after transfemoral transcatheter aortic valve replacement (TAVR). We evaluated safety and feasibility in terms of vascular complications, bleeding, and 30-day outcomes of the collagen-based

Fractional flow reserve (FFR) is the gold standard for assessing the physiological significance of coronary disease during invasive angiography. Evaluation of alternative adenosine-free indexes to elucidate ischemic predicament is ongoing. A total of 255 lesions evaluated with pressure wires in 212